Provider Demographics
NPI:1174191035
Name:SOUPIR, LISA ANNE (NP-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:SOUPIR
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6485 CITY WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3246
Mailing Address - Country:US
Mailing Address - Phone:952-933-1150
Mailing Address - Fax:952-930-3304
Practice Address - Street 1:6485 CITY WEST PKWY
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3246
Practice Address - Country:US
Practice Address - Phone:952-933-1150
Practice Address - Fax:952-930-3304
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7720363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily